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'Z• SERVICE REQUEST <br /> ype of Business or Property FACILITY 10# SERVrItCE REQUEST# <br /> V OG <br /> 0 OPERATOR BUM PARTY <br /> II�latnk�Ca U• S. D <br /> SITE DRESS <br /> 2 01 srrae Nr D4Yreon l[l StrM Name �TYW 4"0 <br /> Mailing Address (If Different from Site Address) <br /> Fb , tztx 3z <br /> CITY ^ ,�k�e CQ TATE ZIP <br /> PHONE 91 err. APN# LINO USE APPLICATION# 7 <br /> czvi) szS-37aa <br /> PHONE#2 em BOSDISTRICT LocATIONCQDE. - <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REQUESTOR BUM PARTY <br /> BUSINESS NAME PHONE# an• <br /> SRy-qb S3 <br /> MAILING ADDRESS I ^y/_ FAX� ,?,q <br /> r O 3 <br /> CrrY MadZ4o /7bl STATE Ck ZIP <br /> BILLING ACKNOWLEDGEMENT: I,the undersgned Property or business owner,operator or authorized agent of same,acknowledge dot ad site andlor pmjea specific <br /> PUBLIC HEALTH SERVICES ENvIR0NNENTAL HEALTH ONGiON hourly changes associated with dit pmjad or activity YAK be billed to me or my business as idenMled on this ban. <br /> I also certify that I have prepared is application and that the work to be performed will be done in aaonfanoe with ad SAN JOAauw CDuNrY Ordinam Codes,Slandards,STATE and <br /> FEDERAL 61M. ��a """ /J(µ• <br /> APPLICANT SIGNATURE: DATE�: QZ^��"`r�L <br /> PROPERTY I BUSINESS OWNER ❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT Jri ISCr K�'� <br /> aAPR.GVR is net OR 81UMP.uev.poet ofwthonzadon to SW angruad Title <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,I,the owner oroperator of the property located at the above site address,hereby authorize the release of <br /> any and all results,geotechnical data andlor envlronmentad5de assessment khferrnation male SAN JOAIXIIN COUNTY PUBLIC HEALTH SERVICES ENVRONMENTAL HEALTH DIVISION as soon <br /> as A is available and at the same time it is provided to me or MY representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: - <br /> rr�D1� <br /> RECUvEn <br /> DEC 71998 <br /> SAN <br /> JOAQUIN COUNTY <br /> INSPECTOR'S SIGNATII E: CORRSIGNATURE: PUBLIC HEALTH SERVICES <br /> RO <br /> APPROVEDBY:r 71 <br /> �v, EsuLoYI: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (H already completed): SERVICECODE: -2 P I Q 3C <br /> Fee Amount t o L Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br />